Youth Club Membership Form – JAMIA SHAN-E-ISLAM

Full Name *

First

Middle

Last

Preferred Name *

Upload a Photo *

Click or drag a file to this area to upload.

Where possible, provide a photo against a plain white background.

Gender *

Date of Birth *//

Contact Priority *

Title *

Name *

First

Last

Home Telephone

Mobile *

Day / Work Telephone

Email *

Confirm Email

A copy of the submitted application form will be sent to this email address.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parental Responsibility *

Any Court Orders Relating To Pupil *

Contact Priority *

Title *

Name *

First

Last

Home Telephone

Mobile *

Day / Work Telephone

Email *

Confirm Email

A copy of the submitted application form will be sent to this email address.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parental Responsibility *

Any Court Orders Relating To Pupil *

Someone (e.g. uncle, aunty, grandparent) who can be contacted in the unlikely event of an emergency, if the mother and father are unreachable.

Contact Priority *

Title *

Name *

First

Last

Home Telephone

Mobile *

Day / Work Telephone

Email *

Confirm Email

Relationship to Child *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please carefully read and agree to to the terms and conditions set out below.

• All questions on this membership form must be completed and signed by the parent or carer before any child takes part.

• Parents and carers must ensure they notify us of any changes to the information given on this form.

• Parents and carers must make arrangements for children to be brought to and from the activity safely and on time. If a parent or carer is not able to collect their child, they need to let us know in advance who will be doing so.

• We cannot take responsibility for any damaged clothing and/or personal items during the activity.

• Parents and carers should ensure children have sufficient water, food, clothing, sun lotion and medication (where appropriate) for the duration of the activity.

I agree to (please tick) *

1. My child taking part in the any activites in the Youth Club
2. The Youth Club keeping a record of this form for health and safety reasons
3. Any medical treatment that my child may need to be given in an emergency
4. *My child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity. (The Youth Club will take all steps to ensure these images are used solely for the purposes for which they are intended.)

*Note: if consent is not given, the Youth Club will not use any images taken during the activity that contain the child/young person.

Agree to Terms & Conditions *

I understand that my child needs to follow the behaviour code and any safety rules so that the Youth Club can keep them and other children safe.

Declaration *

I hereby certify that the information I have supplied is true and correct to the best of my knowledge. I understand that a false statement may disqualify my child for a place in the Youth Club.

Mother's Signature *

Using your finger, please sign on the scratchpad. By signing, you are giving your consent and you agree to all the terms and conditions set out above.

Father's Signature *

Using your finger, please sign on the scratchpad. By signing, you are giving your consent and you agree to all the terms and conditions set out above.